|Year : 2019 | Volume
| Issue : 1 | Page : 14-19
Comparative evaluation of intraorifice sealing ability of different materials in endodontically treated teeth: An In vitro study
Kanwalpreet Kaur Bhullar1, Shantun Malhotra1, Renuka Nain1, Harsheen Bedi1, Ramandeep Singh Bhullar1, Amandeep Singh Walia2
1 Department of Conservative Dentistry and Endodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar, India
2 Deep Dental Hospital and Orthodontic Centre, Ropar, Punjab, India
|Date of Web Publication||24-Jun-2019|
Dr. Renuka Nain
Department of Conservative Dentistry and Endodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, Mall Mandi, Amritsar - 143 007, Punjab
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Coronal microleakage holds importance among various causes of failure after endodontic treatment leading to infection in the periradicular, periodontal ligament, or supporting osseous structures. Loss of coronal seal may occur due to leakage of temporary filling material or fracture of the permanent restoration. Therefore, the use of an intraorifice barrier material would be advantageous in reducing leakage and increasing possibilities for success. Materials and Methods: Fifty single-rooted mandibular premolars were decoronated, cleaned, shaped, and obturated. Gutta-percha was removed to the depth of 3 mm from the orifice. Ten specimens each were sealed with Cention N (Ivoclar Vivadent), Biodentine (Septodont), and glass-ionomer cement (GIC, GC9 high-strength posterior restoration) along with positive and negative control groups, respectively. The teeth were then submerged in dye. Specimens were longitudinally sectioned, and leakage was measured using ×10 stereomicroscope and graded for the depth of microleakage. Results: The samples were subjected to statistical analysis using one-way ANOVA and post hoc Tukey's test and showed that mean microleakage values in all the groups were significantly different from each other (P < 0.001) with the lowest microleakage in Biodentine followed by GIC and Cention N and highest in positive control group. No microleakage was seen in negative control group. Conclusion: The present study concluded that intraorifice barrier placement provides better coronal seal, prevents microleakage, and enhances the longevity of postobturation restorations. Biodentine proved to be the best followed by GIC, Cention N, and control groups.
Keywords: Biodentine, Cention N, glass-ionomer, intraorifice barriers, microleakage
|How to cite this article:|
Bhullar KK, Malhotra S, Nain R, Bedi H, Bhullar RS, Walia AS. Comparative evaluation of intraorifice sealing ability of different materials in endodontically treated teeth: An In vitro study. J Int Clin Dent Res Organ 2019;11:14-9
|How to cite this URL:|
Bhullar KK, Malhotra S, Nain R, Bedi H, Bhullar RS, Walia AS. Comparative evaluation of intraorifice sealing ability of different materials in endodontically treated teeth: An In vitro study. J Int Clin Dent Res Organ [serial online] 2019 [cited 2019 Oct 22];11:14-9. Available from: http://www.jicdro.org/text.asp?2019/11/1/14/260947
| Introduction|| |
The main purpose of endodontic treatment is to clean the root canal system, disinfect it, and shape appropriately to obtain a complete seal. The success of endodontic treatment depends on several factors such as the preoperative status of the root canal, presence of periapical lesion, previous root canal treatment, the root filling quality, and coronal restoration. Microbial infection through an inadequate coronal seal is one of the major factors associated with endodontic failure, and the literature suggests that coronal leakage is more likely to determine clinical success or failure than apical leakage. Thus, the maintenance of coronal seal is equally important as apical seal because saliva dissolves the root canal filling material which results in contamination along the entire root canals and around the apex and development of periapical diseases. Placement of a material over the coronal gutta-percha to act as a barrier to coronal microleakage would be advantageous in reducing leakage and increasing the success of treatment.
Many materials have been investigated for use as an intracoronal seal to prevent microleakage, including Cavit, amalgam, intermediate restorative material, super- ethoxy benzoic acid (EBA), composite resin, glass-ionomer cement (GIC), and mineral trioxide aggregate (MTA). Biodentine is a suitable intraorifice restorative material due to properties of remineralization of dentin, mechanical properties similar to those of dentin, easy use and handling, short setting time, resistance against leakage, and being nontoxic. Ramezanali et al. concluded that calcium enriched mixture (CEM) cement, Biodentine, and MTA are effective for providing an efficient coronal seal when used as an intraorifice barrier in endodontically treated teeth.
GIC has been advocated for use as an intracanal barrier when microleakage or recurrent caries are likely because of its cariostatic and adhesive properties. Basem Salim and Hassan concluded that MTA and GIC when used as intraorifice barrier offered a higher sealing ability at a depth of 1 and 2 mm, while composite showed the least sealing ability. Cention N is an “alkasite” restorative which is a new category of filling material, such as compomer or ormocer and is essentially a subgroup of the composite resin. Samanta et al. evaluated the microleakage in Class V cavity filled with flowable composite resin, GIC, and Cention N and concluded that Cention N exhibited lowest microleakage.
Limited studies are available on the efficacy of Biodentine as intraorifice barriers. No study is available on the use of Cention N as intraorifice material since it is a newly introduced material. Thus, considering the importance of coronal seal and the role of intraorifice barrier in decreasing bacterial microleakage, the need for finding a material with optimal properties for use as an intraorifice barrier is clear. Thus, this in vitro study aimed to assess the coronal microleakage of Biodentine, GIC, and Cention N as intraorifice barriers.
| Materials and Methods|| |
Study sample preparation
Freshly extracted fifty single-rooted mandibular premolars were used for the study. The inclusion criteria were:
- Permanent mandibular teeth
- Had a single root and a single canal with completely developed apices
- Free of caries, cracks, and fractures
- Intact roots, with no signs of internal or external resorption
- No evidence of prior canal treatment.
All specimens were decoronated just apical to the cementoenamel junction. Access cavities were opened and a #10 K-file (Dentsply Maillefer, Ballaigues, Switzerland) was inserted and advanced until it was visualized at the apical foramen. The file was retracted 1 mm and working length was established at this level. After that, the canals were apically prepared up to size #40 using hand files made of nickel–titanium type K-file NiTiflex (Dentsply Maillefer, Ballaigues, Switzerland), and the coronal part was prepared using Gates Glidden Drills (Mani, Tochigi, Japan) of sizes 2 and 3.
During the preparation and before moving to the next file, irrigation was done with 5.25% hypochlorite and 17% EDTA solutions. Once the teeth were prepared, the root canals were dried using paper points (Alphadent, Quezon, Phillippines, USA), obturated using the lateral condensation technique with standard gutta-percha cones (Alphadent, Quezon, Phillippines, USA), and AH Plus root canal sealer (Dentsply, De Trey Konstanz, Germany).
All the fifty prepared teeth were randomly divided into five groups of ten teeth each which were as follows:
- Group I – Biodentine
- Group II – Cention N
- Group III – GIC
- Group IV – Positive control
- Group V – Negative control.
Three millimeter of gutta-percha was removed from the coronal orifice (cementodentinal junction) using Gates Glidden Drills in all the teeth except control groups. The three experimental materials were mixed according to the directions of the manufacturer and placed into access cavity in the respective groups to seal the orifice.
For evaluation of the quality of the coronal seal, the teeth were subjected to dye leakage. The three experimental groups and one positive control group were coated with two layers of nail varnish except at 2 mm area around access restoration. The teeth in negative control group were coated with nail varnish completely. Samples were then submerged in Rhodamine-B dye for 7 days. The samples were then rinsed with running water to remove dye from the external surface. The samples were subsequently longitudinally sectioned with the help of a diamond disc and observed under a stereomicroscope. The leakage was measured using a ×10 stereomicroscope (Olympus SZX16) by measuring the distance from the coronal extent of the orifice material to the greatest depth of penetration of the dye. The dye penetration in the teeth was analyzed using ANOVA and post hoc Tukey's tests.
| Results|| |
[Figure 1] shows longitudinal sections of the teeth showing dye penetration along the materials. [Table 1] and [Figure 2] show mean value of microleakage which is nil in negative control group, lowest in Biodentine (1.506 mm) followed by GIC (2.434 mm), Cention N (2.873 mm), and highest in positive control group (5.856 mm). The data obtained evaluating the coronal seal was subjected to statistical analysis using ANOVA [Table 2] and post hoc Tukey's [Table 3] tests. The computed value of P < 0.001 indicates statistically significant difference among groups under the study.
|Figure 1: longitudinal section of the teeth showing dye penetration along the materials under stereomicroscope|
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|Table 1: Mean and standard deviation of microleakage of tested coronal barrier materials (mm)|
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|Table 3: Multiple comparison using post hoc Tukey's honestly significant difference (P)|
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| Discussion|| |
The success of endodontic therapy depends on a thorough chemomechanical preparation for removal of necrotic debris and bacteria from the root canal, followed by sealing the root canal to prevent ingress of bacteria and tissue fluids. Coronal sealing is considered one of the most important factors in evaluating the success of endodontic treatment. Dow and Ingle stated that failure most commonly occurs due to inadequate apical seal. Studies have shown that a good coronal seal is equally important. Magura et al. found that the failure rate was twice as high in cases without an adequate coronal restoration compared to cases which were adequately restored.
Weak coronal seal can lead to contamination and entry of saliva, nutrients, germs, and their endotoxins into the root canals and hence a failure in the endodontical treatment. Therefore, continuous efforts are made to develop and provide modern filling materials and techniques that achieve an impermeable barrier between the root canal system on one side and the oral environment on the other. Among these modern techniques that limit contamination in endodontically treated root canals, sealing the intraorifices of root canals with different restorative materials before the final restoration have been applied. This technique depends on removing the gutta-percha cones and the root canal cement filler from the canal intraorifice at a specific depth and replacing it with a restorative material that prevents coronal leakage in cases of fractures or loss of the final restoration. Thus, several studies have been conducted to evaluate and compare the various restorative materials used as intraorifice barriers.,
Varghese et al. evaluated the microbial coronal leakage in restored pulp chamber of a root canal in single-rooted teeth and concluded that composite with MTA as base showed least apical leakage and maximum leakage was seen in amalgam, and none of the access restorative materials showed a fluid impervious seal. Jaiswal et al. in their study concluded that coronal seal reduces the microleakage, and light cure GIC has better coronal sealing ability. According to Navya et al., Biodentine when used as intraorifice barrier leaked significantly less than GIC and AH Plus sealer exhibited better sealing ability than ZOE sealer.
Single-rooted mandibular premolar teeth with single canals were prepared in this study to expose their intraorifices. These were selected so as to minimize anatomical variation, allow standardization, and moreover, can be easily restored.
In the current study, depths of 3 mm were used, taking into consideration the probable need to remove the intraorifice barrier if retreatment was required, because placing the restoration in a deeper intraorifice entails greater difficulty and risk when removing it.
Placement of an additional material into the canal orifices after removal of a portion of the gutta-percha and sealer up to 3 mm has several advantages:
- The coronal 3 mm of the canal is an ideal small cavity that is surrounded by intact tooth structure and can be easily sealed
- There is no occlusal load in the orifice area
- There are no esthetic considerations in this method because the material is placed within the canal.
Thermocycling is a standard protocol in restorative literature when bonded materials are evaluated, simulating in vivo aging by subjecting them to cyclic exposures of hot and cold temperatures. Resin composite restorative materials and adhesive systems are sensitive to thermocycling. Thermocycling stress may induce a significant amount of bond fatigue and microleakage at the tooth/restoration interface. Marginal leakage is believed to be result of a difference in coefficient of thermal expansion between restorative material and tooth. Hence, in accordance with a study done by Korasli et al., the samples were thermocycled 500 cycles at 5°C–55°C for 30 s. The criteria of an ideal intraorifice seal were proposed by Wolcott et al. as follows: (1) easily placed, (2) bonds to tooth structure, (3) seals effectively against coronal microleakage, (4) easily distinguished from natural tooth structure, and (5) does not interfere with the final restoration of the access preparation. In the current study, three different restorative materials were chosen (Biodentine, Cention N, and GIC type IX) to investigate the ability of each material at providing a coronal seal for the entry orifices of the root canals of single canal, recently extracted, endodontically treated teeth.
Dye penetration method to check the microleakage is a simple, easy, and cost-effective method. This study used Rhodamine-B dye as it has small particle size, better penetration, water solubility, diffusibility, and hard tissue nonreactivity. The dye has been used under vacuum penetration method as it helps to remove entrapped air which can prevent complete dye penetration.
The results of this study showed that Biodentine had the least microleakage among all groups, followed by GIC and Cention N. Biodentine is a new biocompatible; bioactive material is supplied in the form of a powder in a capsule along with a liquid in a pipette. The powder contains tricalcium silicate, dicalcium silicate, calcium carbonate, calcium oxide, iron oxide, and zirconium oxide. The liquid contains calcium chloride and water-soluble polymer. Biodentine is a suitable material for permanent restoration of dentin as well as endodontic purposes due to optimal properties such as remineralization of dentin, mechanical properties similar to those of dentin, easy use and handling, short setting time, resistance against leakage, and being nontoxic, According to the manufacturer, its setting characteristics and mechanical behavior make it suitable as a dentin substitute for direct posterior restorations. Due to its dimensional stability during setting, reliable marginal sealing of restorations made with this material may presumably be obtained.
Cention N is a urethane dimethacrylate-based, self-curing powder/liquid restorative with optional additional light curing. The liquid comprises dimethacrylates and initiators, while the powder contains various glass fillers, initiators, and pigments. It is radiopaque and contains alkaline glass fillers capable of releasing fluoride, calcium, and hydroxide ions. Due to the sole use of cross-linking methacrylate monomers in combination with a stable, efficient self-cure initiator, Cention N exhibits a high polymer network density and degree of polymerization over the complete depth of the restoration.
GICs, on the other hand, are made primarily of alumina, silica, and polyacrylic acid and self-curing materials. These are commonly presented as an aqueous solution of polymeric acid and a finely divided glass powder, which are mixed by an appropriate method to form a viscous paste that sets rapidly. They show a degree of bioactivity when set that causes them to develop an interfacial ion-exchange layer with the tooth, and this is responsible for the high durability of their adhesion to the tooth surface. They are the only restorative materials that depend primarily on a chemical bond to tooth structure. They form an ionic bond to hydroxyapatite at dentin surface and also obtain mechanical retention from microporosities in the hydroxyapatite. GICs form lower initial bond strength to dentin than resins, (3–7 Mpa). However, unlike resins, they form a “dynamic” bond as the interface is stressed, bonds are broken, but new bonds form. This is one factor that allows GICs to succeed clinically, despite relatively low bond strength. However, they could not overcome the following disadvantages: (1) they set slowly and must be protected from moisture and dehydration during the setting reaction which is not completed for 24 h and (2) they rely on ionic bonding to hydroxyapatite; strong acids should be avoided because they totally eliminate mineral from dentin surface. Hence it could be sensitive to total-etch adhesives for bonding. The present study showed a statistically significant difference between sealing ability of GIC Type IX and Biodentine.
Clinically, the quality of an access restoration cannot be determined. Although experimental studies cannot exactly reproduce clinical conditions, and the relationship of in vitro leakage measurements to the in vivo situation has not yet been established, the most reasonable way of testing the efficacy of coronal restoration is extrapolation of the data obtained from in vitro studies to clinical conditions and long-term clinical evaluation of the results.
| Conclusion|| |
The results of the study showed that:
- The coronal seal is better when Biodentine is used as intraorifice barrier
- Maximal coronal sealing is critical for successful endodontic therapy. In this simulated clinical setting, Biodentine and GIC type IX as an intraorifice barrier offered the highest probability for achieving a maximal coronal seal.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]